Sociology of Health & Health Care: Intersecting Health Inequities
Module 3: Intersecting Health Inequities – Who We Are
Overview of Health Determinants
The Lalonde Report (1974) - "A New Perspective on the Health of Canadians"
This report was a response to three significant crises in Canada:
Rapidly rising expenditures for medical care.
A lack of a corresponding increase in overall health or life expectancy.
The general ineffectiveness of medical interventions for chronic conditions.
The core argument of the report was that medical care, while important, was not the single biggest determinant of health.
Health Field Elements: Identified four primary elements influencing health:
Human biology
Lifestyles
Environment
Health care
The Evolution of Health Promotion in Canada
Initial Definition: Health promotion was first understood as a strategy to educate individuals on how their personal lifestyles contributed to major health problems.
Redefinition of Health Promotion: Evolved to be the process of empowering people to gain greater control over and responsibility for their health through:
Developing critical awareness.
Organizing around social issues.
Enhancing awareness of lifestyle choices.
Committing to addressing social inequity.
The Ottawa Charter for Health Promotion (1986)
Adopted by the World Health Organization (WHO).
Outlined five key strategies to achieve health for all:
Create supportive environments.
Develop personal skills.
Reorient health services.
Strengthen community action.
Build healthy public policy.
The Determinants of Health (Dahlgren and Whitehead, 1991)
This model illustrates a layered approach to health determinants, moving from individual to broader societal factors:
Age, sex, and constitutional factors (innermost layer).
Individual lifestyle factors.
Social and community networks.
Living and working conditions (e.g., housing, water and sanitation, unemployment, work environment, food production, education, agriculture).
General socio-economic, cultural, and environmental conditions (outermost layer, encompassing all others).
Health care services are situated as one component within this complex web.
Gender Identity, Sexuality, and Health
Definitions of Gender and Sex
Sex: Refers to biological attributes, including physical features, chromosomes, gene expression, hormones, and anatomy. It is biological.
Gender: Refers to socially-constructed roles, behaviors, expressions, and identities of girls, women, boys, men, and gender-diverse people. It is related to how individuals are perceived and expected to think and act based on societal organization, not solely biological differences.
Key Distinction: "If you know that the difference is 100\% biological it’s a sex difference. Everything else must be considered a gender difference."
Sometimes, it can be difficult to differentiate between sex and gender influences.
Overall Trends: The Gender Paradox
Women tend to live longer than men but often report being 'sicker' and experiencing more disability.
Men's illnesses are generally more life-threatening.
While the ranking of causes of death is similar for both sexes, male mortality rates consistently exceed those for females (StatCan 2019).
1 Cancer
2 Heart disease
3 Accidents (higher for men); Cerebrovascular disease (higher for women)
4 Respiratory disease
Sex Differences in Mortality
Historical Context: Prior to industrialization, mortality rates for men and women were roughly equal. Higher rates for women historically were often due to high maternal mortality, nutrition issues, lack of birth control, and limited access to medical care.
Current Trends: Male mortality rates now exceed female mortality rates, starting from more stillbirths and infant deaths.
Men consistently experience higher rates of premature death for most causes, including accidents and certain diseases.
Males have significantly higher death rates from external causes, such as motor vehicle accidents and suicide, which contribute to a greater sex gap in life expectancy.
Sex Differences in Cause of Death - Accidents and Suicide
Males (age 18-34) are 4 times more likely to die as a result of an accident than females.
Males (age 18-34) are 3.5 times more likely to die by suicide.
Sex Differences in Morbidity
Morbidity rates are generally higher for females than for males concerning:
Arthritis
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Self-assessed physical and mental health are reported as similar between sexes.
HIV rates are higher for males.
Mental Health
Females have higher rates of mood and anxiety disorders.
Females across age groups more frequently perceive their mental health as fair or poor.
Males have higher rates of hospitalization for mental health issues.
Health of Trans & Gender Diverse People
Face significant employment barriers and economic marginalization; e.g., 13\% have been fired for being trans.
Often avoid public spaces due to fear or discrimination.
Experience high rates of violence; e.g., 20\% have been physically or sexually assaulted for being trans.
Encounter discrimination in medical care; e.g., 10\% have had emergency room care stopped or denied.
Important Considerations Regarding Sex Differences
A sex difference does not imply a difference between all men and all women.
Small differences found in large samples can still lead to statistically significant findings.
Many studies that find no differences are often not reported or published.
Many studies show a high concordance (similarity) between men's and women's health experiences.
Explanations of Sex Differences in Morbidity (Relative Ranking)
Acquired risks (differences in behavior).
Psychological differences in acknowledgment of signs and symptoms, and prior medical care-seeking.
Biological differences.
Willingness to report and talk about illness.
Differing responses of doctors to male and female patients.
Gender Inequality and Restrictive Gender Norms (Model based on graphic)
Sex (Body features, Genes, Genitalia, Hormones) is influenced by the Social Production of Gender Norms (Family, Community, Institutions, Structures and Policies).
This leads to a Gender System defined by power and norms.
This system, along with factors like race, class, age, and ability, shapes an individual's Gendered Social Position (e.g., male, female, marginalized male, marginalized female) across the Life Course.
Gendered social position influences:
Gendered differences in exposure (to health risks).
Gendered health behaviors.
Gendered impacts on accessing care.
Gender-biased health systems.
Gender-biased health research, institutions, and data collection.
These pathways lead to Embodiment and Cumulative Burden, ultimately resulting in Health Inequities and Outcomes.
Social Roles and Health
Waldron (1994) highlighted that social roles significantly influence the adoption of behaviors, which in turn have substantial effects on mortality risk.
Masculinity/Femininity:
A significant number of male deaths are associated with risk-taking behavior.
The concept of "toxic hypermasculinity" is sometimes considered dangerous to men's health, leading to elevated rates of alcoholism, "trophy-hunting" sexual behavior and STDs.
Masculinity, while offering privilege, can also cause privation and constrain men's experiences, alongside its role in female oppression.
Marriage: Associated with better health, particularly for men.
Parenthood: Its health effects are more ambiguous.
Note: When more detailed analyses of the quality of social roles are considered, sex differences in health often diminish and sometimes even reverse.
Measuring the Health Effects of Gender (Phillips 2008)
Gender is a composite of many factors, including social status, income, empowerment, equality, and access to resources.
The health effects of gender are mediated via:
Group-level constraints of sex roles and norms.
Discrimination and marginalization of individuals.
Internalization of the stresses arising from role discordance.
A gender perspective necessitates addressing and retaining complexity and diversity in any summative index.
Intersectionality with Race & Health
Kimberle Crenshaw and Intersectionality
Seminal work in understanding the social construction of race and its interconnections with gender (and class).
Highlights how identities are not independent; for example, Whiteness and Blackness are 'gendered,' and masculinity and femininity are 'raced.'
Key Definitions
Race: A socially constructed category of identity based on a cluster of physical or biological traits or characteristics ascribed to individuals. It is a highly contested term due to histories of exclusion and injustice, often leading to the term "racialized" to emphasize its social construction.
Ethnicity: Emerged in the 1940s. Refers to shared cultural traits, heritage, nationality, culture, and religion. It is more frequently "chosen" by an individual.
Other dimensions of ethnicity: Place of birth, nationality, physical features, language, ancestral origin, religion, culture, tradition, sense of belonging.
Ethnicity is complex and heterogeneous; an individual can belong to more than one group, and an ethnic group itself can be internally diverse. It is also dynamic and changing.
Visible Minorities: Categories of people who are socially distributed – including those of certain races and ethnicities – and who hold a subordinate social position. This term is fraught with methodological pitfalls (Marcionis et al., 1994 & Nestel 2012).
Social Determinants and Inequities in Health for Black Canadians
Anti-Black Racism as a Determinant of Health: A key driver of health inequalities.
Institutional Discrimination: Evidenced in:
Opportunity gaps in education.
Disparities in income and employment.
Substandard housing.
Food insecurity (2.8 times higher for Black Canadians).
There are substantial data gaps in understanding the full extent of these inequities.
uOttawa Interdisciplinary Centre for Black Health (ICBH)
Addresses health disparities observed among people from Black communities.
Works to overcome deficiencies in training for health professionals and research.
Aims to bridge gaps in care and public health policy concerning Black communities.
Immigration & Health Status
The Healthy Immigrant Effect: Immigrants often have lower standardized death rates than Canadian-born individuals upon arrival due to the selectivity of immigrants (often healthy individuals are chosen).
Loss of Advantage Over Time: This health advantage tends to be lost over time due to:
Disadvantaged positions in society.
Stress from problems with integration.
Adaptation to a Canadian lifestyle.
Conclusion (Castañeda et al., 2015): Immigration must be understood as a key social determinant of health in its own right, influencing all other social relationships and directly affecting health and well-being, to make substantive improvements in health outcomes.
Race, Ethnicity, Immigration & Health Status (Specific Examples, Nestel 2012)
Cardiovascular Disease: South Asian people have some of the highest rates in Canada.
Cancer & Diabetes:
Diabetes is higher among South Asian Canadians.
Higher rates of liver cancer.
Higher rates of cervical cancer.
Occupational Illnesses: Racialized people, particularly women, are more likely to be exposed to occupational hazards.
Frameworks for Understanding Race, Ethnicity, Immigration & Health Status (Castañeda et al., 2015)
Behavioral Framework (Most Common): The individual is the primary unit of analysis and intervention, focusing on individual behavioral choices.
Cultural Framework (Second Most Common): Emphasizes the role of assumed group traits, shared beliefs, values, customary practices, or traditions. These influence behaviors, shape choices, and affect perceptions of risk.
Structural Framework (Least Common): Accounts for large-scale social forces that impact health, such as access to care and living/working conditions.
Racism Statement
The Canadian Public Health Association stated in 2018: "We are all either overtly or inadvertently racist."
Forms of Racism
Relational Racism (Most Obvious): Experiences of discriminatory behaviors from people in daily life.
Structural Racism: Perpetrated when social, political, and economic systems fail to address structural inequities between racialized groups.
Epistemic Racism: Dominance of Western knowledge systems and practices.
Social Exclusion: Physically and socially isolates racialized groups from equally benefiting from educational, economic, political, and health systems.
Symbolic Racism: Explicitly negative public responses to forms of relational racism.
Embodied Racism: Reactions of the body to the anxieties of discrimination, alienation, and social violence.
Migration and the Social Determinants of Health (WHO Adaptation, 2008)
Conditions surrounding migration often fuel health inequities and may expose migrants to increased health risks and negative health outcomes.
Contributing Factors:
Individual Factors: Economic class, age, sex, hereditary factors.
Lifestyle Factors: Cultural or linguistic barriers, substance abuse.
Living Conditions: Access to clean water and sanitation, safe housing.
Working Conditions: Access to or existence of jobs providing a living wage.
Social & Community Factors: Existence of discrimination, stigma, social inclusion.
Governance & Socioeconomic Conditions: Existence of legislation and policies affecting migrants' health.
Older Immigrant Women: The Triple Jeopardy Hypothesis
Ethnicity, gender, and age have compounding effects on older immigrant women’s health.
They often experience:
Higher levels of depressive symptoms and other forms of mental health issues.
Difficulties reconciling work and caregiving responsibilities.
Difficulties accessing health care services.
Underutilization of preventive services such as cancer screening and breast self-examination.
Higher rates of breast and cervical cancers.
This highlights the importance of mapping migration and gender as intersecting social determinants of immigrant women’s health.
Indigenous Peoples and Health
Defining Indigenous Peoples (2016 Canadian Census)
Refers to "Indian," "Aboriginal," etc.
Total Indigenous population: 1.7 million
First Nations: 977 thousand
Inuit: 65 thousand
Métis: 588 thousand
Historical Context (Richmond & Cook, 2016)
The Indian Act of 1876 is the only active national-level legislation specific to First Nations people in Canada.
It gave responsibility for health and healthcare for First Nations to the federal government, while general population health was a provincial responsibility.
Originally aimed at assimilation, the Indian Act was developed under the assumption that the Aboriginal population was inferior, unequal, and uncivilized.
Indigenous Health - Mortality
Higher infant mortality rates.
Higher mortality rates, especially in early ages (<39).
Lower life expectancy compared to the non-Indigenous population.
Indigenous Health - Morbidity
Accidents, violence, and poisonings account for one-third of deaths.
High rates of cirrhosis/alcoholism (often linked to violent deaths).
High rates of cervical cancer, associated with less frequent Pap smears and higher rates of cigarette smoking.
Indigenous Health Behaviours (StatsCan, 2012)
Daily Smoking:
Inuit: 48.9\% (highest)
Off-reserve First Nations: 38.5\%
Métis: 37.6\%
Total Aboriginal identity population: 35.0\%
Non-Aboriginal identity population: 15.1\% (lowest)
Heavy Drinking (five or more drinks on one occasion at least once a month):
Off-reserve First Nations: 29.6\% (highest)
Métis: 28.5\%
Total Aboriginal identity population: 27.5\%
Inuit: 26.8\%
Non-Aboriginal identity population: 25.9\% (lowest)
Non-Drinking:
Non-Aboriginal identity population: 24.9\% (highest)
Inuit: 23.5\%
Off-reserve First Nations: 22.5\%
Métis: 20.9\%
Total Aboriginal identity population: 22.5\% (approximate)
Indigenous Women in Canada
The female Indigenous population is growing much more rapidly than the rest of the female population in Canada.
This population is relatively young and has higher fertility rates.
Diabetes is particularly prevalent among Indigenous women.
Indigenous women are considerably more likely to smoke.
The life expectancy of Indigenous women is well below that of non-Indigenous women, with particularly wide gaps in self-perceived health ratings.
Next Class
The next session will delve further into the Social Determinants of Health.